Sic We read with great interest the commentary by Rennie and Cardozo (Vol 105, December 1998)'. Massive haemorrhage is a serious and challenging condition that is often difficult to manage. The article does well in highlighting the variety of treatments of this problem and its lessons should be. learnt by the seasoned pelvic surgeon as well as those who are in training. We fully endorse the comments made by the authors regarding the difficulty in keeping pace with coagulation deficit in the face of intractable haemorrhage. The implications of this catastrophe are even more pronounced in the more frequently encountered obstetrical haemorrhage. We had similar h o m t j h g experiences twice in the last six months during elective caesarean sections. The two cases were performed due to previous caesarean section and associated placenta praevia and both culminated in caesarean hysterectomy due to massive intrapartum blood loss. In our second case a consultant haema-tologist was involved at an early stage, and cryoprecipitate, fresh frozen plasma and platelets were given appropriately. Despite trans-fusing 41 units of blood there was no haematological evidence of a coagulation deficit, yet massive haemorrhage continued necessitating packing the abdomen as a temporary measure to stop the bleeding. It was removed forty-eight hours later uneventfully. Bleeding caused by coagulation disorders is at microvascular level and all the blood components used in replacement therapy cannot plug up holes in larger arteries and veins. The difficulty with haemorrhage in the pelvis stems from lacerations of deep pelvic veins, and can vary in magnitude from trivial to life threatening. Pelvic veins may be fragile, tortuous, hidden from view, and distended. Moreover gynaecological surgeons do not have the luxury of using tourniquets to control bleeding. Another moral to the story is that whenever extensive pelvic dis-section is anticipated or encountered intraoperatively, the help given by a haematologist at an early stage may have a considerable impact on the outcome. Additionally, a member of the operating or anaesthetic teams should be dedicated to monitor blood loss and replacement. In the excitement of the moment it is very possible to lose count of the number of units of blood, blood components, crystal-loids and other fluids that have been given as well as the amount of blood loss. One strength of the article is the surgeons' realistic appraisal of their limitations; it is a wise individual who knows when to seek assistance. The attitude of the surgeon may be the deciding factor in the outcome of the situation, a point worth stressing in the training of junior surgeons. Reference 1 Aberdeen Endometria1 Ablation Trials Group. A randomised trial of endometrial ablation versus hysterectomy for the treatment of dys-functional uterine bleeding: outcome at four years. Br J Obstet Gynaecoll999; 106 360-366. 0 RCOG 1999 Br J Obstet Gynaecol 106,874-876

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Objectives

Objective To determine whether twins born second are at increased risk of perinatal death because of complications during labour and delivery. Design Retrospective cohort study. Setting Scotland, 1992 and. Participants All twin births at or after 24 weeks' gestation, excluding twin pairs in which either twin died before labour or delivery or died during or after labour and delivery because of congenital abnormality, non-immune hydrops, or twin to twin transfusion syndrome. Main outcome measure Delivery related perinatal deaths (deaths during labour or the neonatal period).Results Overall, delivery related perinatal deaths were recorded for 23 first twins only and 23 second twins only of 1438 twin pairs born before 36 weeks (preterm) by means other than planned caesarean section (P > 0.99). No deaths of first twins and nine deaths of second twins (P=0.004) were recorded among the 2436 twin pairs born at or after 36 weeks (term). Discordance between first and second twins differed significantly in preterm and term births (P=0.007). Seven of nine deaths of second twins at term were due to anoxia during the birth (2.9 (95% confidence interval 1.2 to 5.9) per 1000); five of these deaths were associated with mechanical problems with the second delivery following vaginal delivery of the first twin. No deaths were recorded among 454 second twins delivered at term by planned caesarean section. Conclusions Second twins born at term are at higher risk than first twins of death due to complications of delivery. Previous studies may not have shown an increased risk because of inadequate categorisation of deaths, lack of statistical power, inappropriate analyses, and pooling of data about preterm births and term births.